Antiepileptic drugs: the old and the new

Antiepileptic drug use and mortality among community-dwelling persons with Alzheimer disease

Objective

To evaluate the risk of death in relation to incident antiepileptic drug (AED) use compared with nonuse in people with Alzheimer disease (AD) through the assessment in terms of duration of use, specific drugs, and main causes of death.

Methods

The MEDALZ (Medication Use and Alzheimer Disease) cohort study includes all Finnish persons who received a clinically verified AD diagnosis (n = 70,718) in 2005–2011. Incident AED users were identified with 1-year washout period. For each incident AED user (n = 5,638), 1 nonuser was matched according to sex, age, and time since AD diagnosis. Analyses were conducted with Cox proportional regression models and inverse probability of treatment weighting (IPTW).

Results

Nearly 50% discontinued AEDs within 6 months. Compared with nonusers, AED users had an increased relative risk of death (IPTW hazard ratio [HR], 1.23; 95% confidence interval [CI], 1.12–1.36). This was mainly due to deaths from dementia (IPTW HR, 1.62; 95% CI, 1.42–1.86). There was no difference in cardiovascular and cerebrovascular deaths (IPTW HR, 0.98; 95% CI, 0.67–1.44). The overall mortality was highest during the first 90 days of AED use (IPTW HR, 2.40; 95% CI, 1.91–3.03). Among users of older AEDs, relative risk of death was greater compared to users of newer AEDs (IPTW HR, 1.79; 95% CI, 1.52–2.16).

Conclusion

In older vulnerable patients with a cognitive disorder, careful consideration of AED initiation and close adverse events monitoring are needed.

Antiepileptic Drug Use and the Risk of Stroke Among Community-Dwelling People With Alzheimer Disease: A Matched Cohort Study

Background People with Alzheimer disease ( AD ) are more predisposed to seizures than older people in general, and use of antiepileptic drugs ( AED s) is more frequent. AED use has been linked to a higher risk of vascular events in the general population; however, it is not evident whether the same risk exists in people with AD . We assessed the risk of stroke associated with incident AED use among people with AD . Methods and Results The MEDALZ (Medication Use and Alzheimer's Disease) cohort includes all Finnish people who received a clinically verified AD diagnosis (N=70718) from 2005 to 2011. People with previous strokes were excluded. For each incident AED user (n=5617) one nonuser was matched according to sex, age, and time since AD diagnosis. Analyses were conducted with Cox proportional hazards models and inverse probability of treatment weighting. Compared with nonuse, AED use was associated with an increased risk of stroke (inverse probability of treatment weighting hazard ratio ( HR ), 1.37; 95% confidence interval [CI], 1.07-1.74). The risk was strongest during the first 90 days (adjusted HR , 2.36; 95% CI , 1.25-4.47) of AED use. According to stroke type, the association was with ischemic strokes (inverse probability of treatment weighting HR , 1.34; 95% CI , 1.00-1.79) and hemorrhagic ones (inverse probability of treatment weighting HR , 1.44; 95% CI , 0.86-2.43). The stroke risk of users of older AED s did not differ from that of the users of newer AED s (adjusted HR , 1.04; 95% CI , 0.71-1.53). Conclusions AED use was related to an increased risk of stroke, regardless of AED type. Our results highlight caution in AED use in this vulnerable population.

Adult Status Epilepticus: A Review of the Prehospital and Emergency Department Management

Seizures are a common presentation in the prehospital and emergency department setting and status epilepticus represents an emergency neurologic condition. The classification and various types of seizures are numerous. The objectives of this narrative literature review focuses on adult patients with a presentation of status epilepticus in the prehospital and emergency department setting. In summary, benzodiazepines remain the primary first line therapeutic agent in the management of status epilepticus, however, there are new agents that may be appropriate for the management of status epilepticus as second- and third-line pharmacological agents.

Drug utilisation study in patients receiving antiepileptic drugs in Colombia

INTRODUCTION

This study examines the indications according to which antiepileptic drugs are prescribed and used in a population of patients enrolled in the Colombian national health system (SGSSS).

METHODS

Retrospective cross-sectional study. From the pool of individuals in 34 Colombian cities who used antiepileptic drugs between 18 July, 2013 and 31 August, 2014 during a period of no less than 12 months, we obtained a random sample stratified by city. Socio-demographic, pharmacological and comorbidity variables were analysed. Continuous and categorical variables were compared, and logistic regression models were used.

RESULTS

Our patient total was 373 patients, with 197 women (52.1%) and a mean age of 41.9 ± 21.7 years; 65.4% of the patients were treated with monotherapy. The most frequently used drugs were valproic acid (53.1%) and carbamazepine (33.2%). Epilepsy was the most frequent indication (n=178; 47.7%); however, 52.3% of the patients were prescribed antiepileptics for different indications, especially neuropathic pain (26.8%), affective disorders (14.2%) and migraine prophylaxis (12.3%). A total of 81 patients with epilepsy (46.6%) displayed good seizure control while another 25 (14.4%) had drug-resistant epilepsy. In the multivariate analysis, medication adherence was associated with a lower risk of treatment failure in patients with epilepsy (OR: 0.27; 95%CI, 0.11-0.67).

CONCLUSIONS

In Colombia, antiepileptic drugs are being used for indications other than those originally intended. Monotherapy is the most commonly used treatment approach, together with the use of classic antiepileptic drugs.

Levetiracetam

The incidence of neonatal seizures varies according to gestational age, weight, and cause. Seizures occur in an estimated 1.0-3.5 per 1,000 term infants1 with an increased incidence of 10-130/1,000 in preterm infants.2 Most neonatal seizures have a specific cause.3 Hypoxic-ischemic encephalopathy has been identified as the most common etiology associated with neonatal seizures, accounting for 50-60 percent of the cases.4 Table 1 outlines common causes of neonatal seizures. Early recognition of seizures and appropriate treatment is vital in preventing multiorgan dysfunction and permanent brain damage.